Synopsis After clearing Bridge 11 during an upbound transit of the Welland Canal, Ontario, at night and in thick fog, the ZIEMIA CIESZYNSKA veered to starboard and grounded on the western bank. The vessel was under the conduct of a pilot. Soon after, she was refloated, unassisted, and proceeded, under her own power, to a lay-over berth in the canal. The vessel sustained considerable damage to the forward underwater area. There was neither pollution nor injury as a result of this occurrence. The Board determined that the ZIEMIA CIESZYNSKA grounded because the pilot, while disorientated, made an unexpected and erroneous alteration of course. The sudden formation of advection fog and the fact that there was no continuous exchange of information between the pilot and the master also contributed to the grounding. 1.0 Factual Information 1.1 Particulars of the Vessel 1.1.1 Description of the Vessel The ZIEMIA CIESZYNSKA is a typical bulk carrier with bridge, engine-room and accommodation located aft. The wheel-house is equipped with a complete computer-assisted bridge instrumentation control centre. Radars are sited at the port and starboard extremities of the forward control console. 1.2 History of the Voyage The ZIEMIA CIESZYNSKA departed from Lock 7 in the Welland Canal at 23153, 21 September 1993, continuing her upbound (north to south) transit. The vessel was under the conduct of a Seaway pilot who had recently boarded. At 2352, the vessel passed through Bridge 10 and, shortly thereafter, there was a change of navigation bridge personnel. In addition to the pilot, the master, an officer of the watch (OOW), a helmsman and ship's electricians were on the bridge at midnight. As the ZIEMIA CIESZYNSKA was approaching Bridge 11 (see Appendix A), the master was monitoring the starboard radar and the pilot was navigating by visual aids. The pilot glanced at the radar for periods of two to three seconds occasionally. North of Bridge 11, the pilot requested that an all round white light be fitted to the crosstrees of the foremast to aid him with his navigation. The vessel cleared Bridge 11 at 0013, 22 September. Suddenly, dense fog obscured the white light on the foremast and reduced visibility in the channel, except for a narrow area along the west bank which was illuminated by lights, two of which were visible. The pilot ordered hard-a-starboard helm explaining that the vessel had to pass between the two white lights. The speed of the vessel was estimated to be four to five knots. The master, observing by radar that the vessel was centre channel, countermanded the order and ordered hard-a-port helm, but there was insufficient time to prevent the vessel from running aground. The master, perceiving that the pilot was totally disoriented, took over the conduct of the vessel and verbally relieved the pilot of his duties. The pilot initially could not remember and later denied giving the hard-a-starboard order, but the bridge course recorder clearly shows a dramatic alteration of course to starboard at 0013. The vessel's original heading was 188 (G), and she grounded heading 248 (G) (see Appendices A and B). The helmsman testified that he had been ordered to alter course to starboard by the pilot and that there had been no inadvertent movement of the helm. The pilot further surmised that perhaps the vessel had taken a sheer due to bank suction caused by a change in the profile of the underwater area of the canal. An underwater survey of the area conducted at a later date did not discover anything to support this conjecture. As the bridge operator was lowering the bridge, he saw the stern of the ZIEMIA CIESZYNSKA, approximately 60 m distant, moving rapidly toward the east. He estimated that the bow of the vessel was 45 to 50 degrees from the centre line of the channel toward the western shore, near a spar buoy. The vessel grounded at 0014 in position 4304'24 N, 7912'36 W. The ZIEMIA CIESZYNSKA was quickly refloated and resumed her passage under the conduct of the master. Soundings of compartments were taken. These revealed that the forepeak tank and the starboard No. 1 double-bottom tank had been breached. The vessel's pumps were unable to contain the inflow of water. Because of the deepening forward draught, the vessel was directed to tie-up at Wharf No. 10, a berth which is located in a basin outside of the canal itself. When she was secured there at 0320, the draught was read and found to be 8.35 m forward, 8.2 m amidships and 7.95 m aft. 1.3 Injuries to Persons 1.4 Damage to the Vessel The vessel sustained considerable damage to the underwater plating and to the frames of the forepeak tank and the starboard No. 1 double-bottom tank. 1.5 Certification 1.5.1 Vessel The vessel was certificated, manned and equipped in accordance with existing regulations. 1.5.2 Personnel Both the master and the OOW held qualifications appropriate for the class of vessel on which they were serving and for the voyage being undertaken. The pilot was duly licensed by the Great Lakes Pilotage Authority. 1.6 Personnel History 1.6.1 Master The master had served in this capacity for 15 years. He had been in command of the ZIEMIA CIESZYNSKA since her delivery in March 1993. 1.6.2 Officer of the Watch The OOW had served in his present capacity for two years and he also had been on the ZIEMIA CIESZYNSKA since her delivery. 1.6.3 Pilot The pilot had been handling vessels in the Great Lakes area for 20 years. Previously, he had been master of vessels in Canadian waters and had the appropriate certification. Before this particular assignment, the pilot had been off duty for 72 hours. The pilot has since retired from the Great Lakes Pilotage Authority. 1.6.3.1Medical Requirements As the pilot was over 55 years of age, he was required to undergo a complete medical examination every year. His last such examination was conducted in February 1993 at which time he was reported to be fit for duty. 1.7 Environmental Information 1.7.1 Weather Advection fog is prevalent in the area in autumn. During the evening, there had been intermittent light rain with a visibility of seven to eight miles. After 2300 on 21 September, the air temperature and the dew point coincided at 10C and fog was observed to develop ashore. Shortly after midnight, the channel became obscured in dense fog. Wind was from the NW at about two knots. 1.7.2 Flow of the Canal On the west bank of the canal, approximately 230 m south of Bridge 11 and marked by two spar buoys, there is a hydro weir. This weir controls the level of water in the canal between Locks 7 and 8 by regulating the amount of water flowing out of that section of the canal. The outflow at the weir varies from 10 m3 to 12 m3 per second. Reports indicate that, at the maximum discharge, there is little or no lateral effect on the north/south flow of the canal. 1.8 Navigation Equipment 1.8.1 Vessel The ZIEMIA CIESZYNSKA is equipped with a full range of ultra-modern navigational aids including a course recorder. The sophisticated starboard radar is equipped with an Automatic Radar Plotting Aid (ARPA). The steering control is a small hand-operated wheel. At the time of the incident, two steering motors were running, providing a wheel-over time of 14 seconds from hard-a-port to hard-a-starboard. 1.8.2 Canal Lighting South of the position of the grounding, on the eastern shore, between Bridge 11 and Mile 11, two lights are set well back from the canal edge. At the turn in the canal at Mile 11, there is a white light on the eastern bank. Lights on the western shore of the canal are spaced approximately 100 m apart and set some 15 m from the canal edge. At Mile 11, a white light on the western bank is positioned higher than the white light on the eastern bank. The intensity of the canal lighting is controlled by the operator at Bridge 11. As the visibility decreases, the candle-power can be increased. However, with maximum power in reduced visibility, the glare caused by the diffusion of light in the suspended water particles of the fog may obscure the edge of the canal. At the time of the occurrence, the candle-power of the lights was nearly at maximum, the east bank of the canal was not visible and the first two lights south of Bridge 11 on the west bank of the canal were barely visible. 1.9 Radio Communications and Television Monitoring The St. Lawrence Seaway Authority Welland Canal Traffic Control Centre (Seaway Welland) co-ordinates vessel traffic through the canal. The controller monitors very high frequency radiotelephone (VHF R/T) channel 14 (in sector 2) and, during adverse weather conditions, monitors television video units to advise shipping of local conditions such as high winds and/or reduced visibility. Transiting vessels have to report to Seaway Welland and advise of their progress. At 2300, 21 September 1993, Seaway Welland advised of areas of ground fog but, at the time, these areas were not considered to be significant enough to affect vessel movement. 1.10 Canal Traffic Control Whenever fog is present, certain areas of the canal may be shut down and, if the visibility is reduced to less than one-quarter of a mile, the whole system may be shut down. At 2400, the ZIEMIA CIESZYNSKA was in fog but was committed to continue ahead since she was transiting a no meeting area where there are no tie-up facilities. The ZIEMIA CIESZYNSKA ran aground at 0014. This information was relayed to Seaway Welland at 0030. Downbound traffic from Lock 8 was stopped to permit the ZIEMIA CIESZYNSKA to proceed to Wharf No. 10, near Mile 17, after the grounding. 1.11 Interaction Between the Pilot and the Bridge Personnel The pilot is responsible to the master for the safe navigation of the ship. He has a duty to inform the master or his representative of the action he will take to accomplish this task. There was no language difficulty in communicating the necessary orders. Apart from helm orders being given by the pilot and being acknowledged, conversation on the bridge was kept to a minimum. There was little exchange of information between the master and the pilot. The master retained control of the radar, a type with which the pilot was not familiar. The pilot was navigating by visual means. 1.12 Health Concerns Following the incident, the pilot was unable to recall the events leading up to the grounding. The moment of disorientation leading to the extraordinary helm order which resulted in the grounding gave rise to concern for the medical condition of the pilot. The TSB Safety Medicine Branch conducted a review of the pilot's medical records. At the time of the review, the records indicated that the pilot was fit for duty.